ueg education Mistakes in… 2020
Mistakes in pouchitis and how to avoid them
Jonathan P Segal, Susan K Clark and Ailsa L Hart
Restorative proctocolectomy can be considered a quality-of-life surgical procedure for patients who have ulcerative colitis that has not responded to medical therapy, and for some patients who have familial adenomatous polyposis. The procedure removes the entire diseased large bowel and utilises the patient’s small bowel to create a reservoir that allows defaecation without the need for a long-term ileostomy. Despite generally good outcomes, complications can occur. One of the most frequent problems is primary idiopathic pouchitis, which is characterized by increased stool frequency, haematochezia, abdominal cramping, urgency, tenesmus, incontinence, fever and flare-up of extraintestinal manifestations.1 The incidence of acute primary idiopathic pouchitis following surgery has been reported to be 20% at 1 year, and up to 40% at 5 years.2 Chronic primary idiopathic pouchitis develops in 10–15% of all patients who undergo restorative proctocolectomy for ulcerative colitis and can be ‘responsive’ or ‘refractory’ to antibiotic therapy. Chronic pouchitis is defined as symptoms of pouchitis that persist beyond 4 weeks or multiple relapses of acute pouchitis within a year.3,4 Here we discuss mistakes in the assessment and management of primary idiopathic pouchitis and how best to avoid them. Most of the discussion is evidenced based, but where evi- dence is lacking the discussion is based on our extensive clinical experience of treating patients who have pouch dysfunction.
Mistake 1 | Assuming all pouch dysfunction Campylobacter, Salmonella, Candida or pelvic sepsis on MRI.7 It is therefore imperative to is primary idiopathic pouchitis without cytomegalovirus), pelvic sepsis, faecal stasis, thoroughly assess a dysfunctional pouch with MRI. excluding alternative diagnoses ischaemia or drugs (particularly NSAIDs).8 The potential consequences of missing this When patients present with symptoms related diagnosis are inappropriate use of antibiotics, There are no validated scoring systems available to their pouch it is important to be mindful that antibiotic resistance, side effects and worsening to define pouchitis. The pouch disease activity other possible causes (e.g. hyperthyroidism, clinical state. Furthermore, by missing pelvic index (PDAI)5 is used in the research setting but it coeliac disease or pouch cancer) are excluded. sepsis and assuming symptoms are primary remains unvalidated and its routine use in clinical This is best done by following an algorithm, such idopathic pouchitis, there is the potential practice is rare. as the one presented in figure 1.9 to escalate to biologics, which may cause Importantly, there can be a lack of correlation It is essential to take a robust history, perform immunosuppression and worsening sepsis. between symptoms, endoscopic activity a thorough examination and offer timely Should pelvic sepsis be found, appropriate and histological findings, leading to potential investigations (including pouchoscopy and antibiotic therapy should be considered, with a misdiagnosis.6,7 Furthermore, there is a radiological examination) before confirming a multidisciplinary discussion to plan management tendency to label every patient who has pouch diagnosis of primary idiopathic pouchitis. An that may include drainage and diversion. dysfunction as having pouchitis; primary important question to ask is “Has the pouch ever idiopathic pouchitis is often diagnosed without worked well?” If this is not the case, a diagnosis Mistake 3 | Not systematically assessing endoscopic and histological confirmation, which of anastomotic leak/pelvic sepsis needs and reporting all pouch regions can result in other pathologies being missed. In careful consideration. Importantly, it is essential endoscopically addition, patients often self-diagnose primary to establish the baseline pouch function for an idiopathic pouchitis based on their symptoms, individual patient; the median 24-hour stool Thorough endoscopic assessment is vital to without objective markers of inflammation or frequency is four to eight, with roughly half of help understand the potential reasons for a endoscopic assessment being used. patients needing to defecate at night. poorly functional pouch. However, no validated It is also important to distinguish between endoscopic reporting systems, key performance primary and secondary types of pouchitis. Mistake 2 | Missing pelvic sepsis as a cause indicators, training or certification are available to Primary idiopathic pouchitis is defined as of pouchitis assess competency in pouchoscopy. Furthermore, pouchitis when all secondary causes have been there is considerable variation in the quality of excluded, whereas secondary pouchitis can In one retrospective study, more than a third of endoscopy reports and efforts have only recently be due to Crohn’s disease, infection (e.g. with patients considered to have antibiotic-dependent been made to develop a reporting template Clostridiodes [formerly Clostridium] difficile, pouchitis were actually found to have evidence of specific to pouchoscopy.10 The standardised
© (2020) Segal, Clark and Hart. Surgery and Cancer, Imperial College London, United Kingdom. Correspondence to: [email protected] Cite this article as: Segal JP, Clark SK and Hart AL. Mistakes in Ailsa Hart is a consultant gastroenterologist at St Mark’s Hospital, Conflict of interest: The authors declare they have no conflicts of pouchitis and how to avoid them. UEG Education 2020; 20: 7–11. Harrow, United Kingdom and in the Faculty of Medicine, interest to declare in relation to this article. Jonathan Segal is a specialist gastreonterology registrar and Department of Metabolism, Digestion and Reproduction, Imperial Published online: July 9, 2020. Susan Clark is a consultant colorectal surgeon at St Mark’s College London, United Kingdom. Hospital, Harrow, United Kingdom and in the Department of Illustrations: J. Shadwell.
7 ueg education Mistakes in… 2020 reporting template introduced is a systematic tool respond to medications such as tricyclic poor outcomes and such surgery is done highly that prompts examination of the anal/perineal antidepressants. selectively. region, rectal cuff, anastomosis, lower and upper There are essentially two scenarios that pouch body, pouch inlet and pre-pouch ileum, but Mistake 5 | Not recognising the presence lead to a diagnosis of ‘Crohn’s disease of the it is not widely used. of cuffitis pouch’. The first arises when there has been a Other problems with pouchoscopy include preoperative diagnosis of Crohn’s disease, and poor intra- and inter-rater reliability between When forming a pouch, there is an anastomosis the second is the development of Crohn’s-like pouchitis scoring systems,11 with some of the between the ileal pouch and the anorectum. features after the formation of a pouch in a PDAI descriptors considered inappropriate for In some situations, this area—refered to as the patient who has ulcerative colitis. assessing endoscopic disease activity in cuff—can become inflamed, resulting in ‘cuffitis’. In one long-term study, 2–8% of patients pouchitis. This suggests that we need better Essentially this is residual ulcerative proctitis. who originally underwent restorative validated scoring systems for assessment of The symptoms of cuffitis are characterised by the proctocolectomy for presumed ulcerative colitis pouch inflammation.11 frequent passage of stool with small quantities of had their original diagnosis changed to Crohn’s We suggest that endoscopic examination of a blood,13 urgency and pain and it can, therefore, be disease.21 We believe it is important to diagnose pouch is performed by experienced endoscopists mistaken for pouchitis. Crohn’s disease of the pouch accurately to help and that a systematic template should be used to A digital examination should be performed to with prognostication and offer appropriate encourage examination (and biopsy) of all pouch manually feel the cuff. A long retained rectal cuff treatment. The criteria utilised to diagnose regions and recording of findings. Photographic (longer than 2cm) is more prone to inflammation. Crohn’s disease are varied. Some studies have evidence of the pouchoscopy can also help Endoscopic evaluation is required to directly defined Crohn’s disease of the pouch as assessment. visualise the cuff, with biopsy samples taken including: inflammation of the pouch that is for histological assessment to confirm the resistant to antibiotic treatment, stricturing of the Mistake 4 | Failing to appreciate the impact diagnosis.13–15 The incidence of inflammation afferent limb, stricturing of the small bowel, or of symptoms on quality of life of the retained anorectum has not been fistulating disease.27–30 Furthermore, the presence extensively studied; some studies report a 9% of pre-pouch ileitis is controversial—some There is a large variation in how different patients incidence.16 studies suggest this may be an endoscopic perceive their pouch symptoms and how their The treatment for cuffitis differs from that feature of Crohn’s disease,31,32 but this has been symptoms impact on their overall quality of life for pouchitis and so distinguishing the two disputed by others.33 (QoL). There can also be a disconnect between is key. Although cuffitis is a poorly studied It is likely that Crohn’s disease of the symptom burden and the severity of inflammation condition, there is evidence that mesalamine pouch is an overused diagnosis, with one study noted in the pouch. Indeed, some patients with suppositories14 may provide some benefit, with highlighting that histological confirmation of very minimal objective inflammation noted steroid suppositories as a second-line therapy.17 Crohn’s disease was found in only 20% of patients endoscopically and histologically can have pouch Essentially the management of cuffitis is the who underwent pouch excision for Crohn’s function that severely impacts on their quality of same as treating ulcerative proctitis. disease of the pouch.33 It is also important to life, whereas other patients can report minimal appreciate that strictures and fistulas that may symptoms but have severe inflammation noted. Mistake 6 | Labelling the diagnosis as mimic Crohn’s disease can be caused by It is essential to be conscious of this variability Crohn’s disease when the features may be other factors such as sepsis, anastomotic and discrepancy, so that investigation and due to another aetiology complications (e.g. leak and/or stricture) or management is tailored to the individual patient. ischaemia. We therefore suggest that Crohn’s In patients who have a high symptom burden Prior to pouch formation a thorough pre-surgical disease of the pouch should only be diagnosed but little inflammation, other causes of their assessment must be considered to rule out by conclusive histology (i.e. granulomas symptoms should be explored along with all Crohn’s disease, to include small-bowel studies, supporting Crohn’s disease) and/or the presence supportive options available, including histological samples reviewed for the presence of characteristic skip lesions in the small bowel. psychological support. of granuloma and the absence of a history of The timing of when the Crohn’s-like problems of The clinical scoring systems do not take into perianal disease. A preoperative diagnosis of the pouch occur can often aid diagnosis—fistulas account QoL indicators that may be significant to Crohn’s disease of the pouch is a relative especially around the anastomosis that occur a patient, which means it is vital to consider contraindication to pouch surgery18 because of the within a year of pouch formation are likely to a patient’s quality of life when assessing high rate of complications and pouch be related to the surgery itself, whereas symptomatology. We recommend that a broad failure.19–21 Indeed, it has been estimated that complications beyond this point could represent range of domains (including effect on personal pouch excision rates are 45–55% in patients de novo Crohn’s disease, but this still requires life, work, sexuality and overall quality of life) who have a preoperative diagnosis of Crohn’s thorough investigation. are taken into account. To aid such assessment, disease21,22 and that the pouch retention rate We also believe that it can be unhelpful and a multidisciplinary team of pouch and stoma 5 and 10 years after formation is 58% and 50%, confusing for patients to hear that their diagnosis nurses, psychologists, clinicians and patient-to- respectively.23 Despite this, some small studies has changed from ulcerative colitis to Crohn’s patient support can be valuable when helping have shown that in the absence of perianal or disease and suggest it is more useful to patients with pouch-related issues. small-bowel disease, restorative proctocolectomy explain that they have active inflammatory Specifically, it is important to assess the can be performed with similar outcomes to those bowel disease. It is more beneficial for the mental health of a patient who has poor pouch who have a pouch for ulcerative colitis.24,25 Indeed, patient to be clear on the strategies of care for function and offer them psychological support. the European Crohn’s and Colitis Organisation managing their problem, whether it be a There has been evidence to show that adjuncts (ECCO) suggest that restorative proctocolectomy fistula, stricture or inflammation, using the such as biofeedback may be beneficial.12 Irritable can be offered to patients who have Crohn’s appropriate combination of surgical/endoscopic pouch syndrome (analogous to irritable bowel disease without perianal disease or small-bowel and medical therapies, than to become syndrome) is diagnosed when no other pathology involvement,26 but we suggest that patients are bogged down in semantics regarding is present to explain symptoms, and may very carefully counselled about the potential terminology.
8 ueg education Mistakes in… 2020
cautiously, especially in the elderly.37 We as t e ouc e e o ked e e advise regular reassessment of patients on ist r at is t e ti ing o inc eased ouc s to s in e ation to su ge long-term antibiotics, including QoL assessment, uesti ns o an e ious s to atic e isodes a e ou ad sing e e sus ecu ent e sus ongoing endoscopic and radiological investigations and o a e ou s to s e ious es onded to anti iotics consideration of alternative medications where at is ou ast isto o gast ointestina in ections and at appropriate. As already described, more is ou t a e isto than a third of patients considered to have at i an s ste ic s to s do ou a e antibiotic-dependent pouchitis were found to at i an e t aintestina s to s do ou a e skin e e oints have evidence of pelvic sepsis on MRI7 and hence • Do you experience difficult evacuation? at edications do ou take inc uding s this should be excluded before a diagnosis of chronic antibiotic-dependent primary idiopathic pouchitis is made.
nc eased e uenc ain onside e i ica anti iotics Mistake 8 | Commencing biologics without c a ing incontinence de endent on ti e to o tain S t s fully reassessing the diagnosis and patient eeding a o iate in estigations needs
If antibiotics fail to control chronic pouchitis, biological therapies can be considered; however, Bloods (FBC, biochemistry, inflammatory sepsis must be excluded before embarking on n esti ati ns a ke s ae atinics coe iac se o og iagnose i a this. Limited evidence—based on small case t oid unction idio at ic ouc itis series and not randomised controlled trials— too cu tu es e c ude in ections and Exclude differential indicate that, overall, anti-TNF therapies are Clostridiodes difficile) diagnosis associated with a 45–58% response rate.38 aeca ca otectin Anti-TNF agents were the first to show some ouc osco benefit for patients with refractory pouchitis, M e is to e c ude e ic se sis with emerging data that ustekinumab39 M to e c ude u st ea s a intestine 40 o st ictu es signs o o n s disease and vedolizumab may also be effective. Non-biologic alternatives, such as alicaforsen (an antisense oligonucleotide), may be an option E lude n la at r but formal results from a phase 3 trial have not differential • Cuffitis (may coexist with pouchitis) yet been published.41 dia n sis o n s disease Importantly, if a patient requires biologic e ani al therapies, their symptom burden is usually quite n o o out o o st uction e g anasto otic stenosis severe and hence ongoing objective assessment a ese oi un ti nal of drug effectiveness and exploration of quality acuation diso de of life are essential. We recommend that patients eak s incte are counselled thoroughly prior to starting Se sis biologics and, where possible, they have a joint eak e ic se sis consultation with an experienced pouch surgeon t er to discuss alternatives (pouch diversion or • Pancreatic insufficiency excision). Chronic pelvic sepsis must be excluded acte ia o e g o t oe iac disease using cross-sectional imaging. Clear timelines oid d s unction must be discussed with the patient when ance o t e ouc planning a strategy of care, so that if biologic drugs do not achieve the predetermined goals Figure 1 | Evidence-based algorithm for the diagnosis of primary idiopathic pouchitis. Adapted with permission set with the patient, alternative options are from Segal JP, et al. 2017; 45: 581–592 © (2016) John Wiley & Sons Ltd. Aliment Pharmacol Ther sought.
Mistake 9 | Failing to optimise diet and Mistake 7 | Failing to reassess patients adverse effects of these medications, fluid intake regularly when they are taking long-term which include tendinopathy in the case of antibiotic treatment ciprofloxacin35 and peripheral neuropathy in As for all forms of IBD, validated, robust and the case of metronidazole (see figure 1).36 In consistent data on which to base dietary advice Chronic primary idiopathic pouchitis develops particular, patients should be made aware of for patients with pouchitis are lacking. There is in approximately 10–15% of patients with acute the risks of long-term antibiotic use and other evidence that fruit consumption can reduce the pouchitis and it can be ‘responsive’ or ‘refractory’ therapeutic options considered. incidence of primary idiopathic pouchitis42 and to antibiotic therapy.3,4 Some of these patients The long-term use of antibiotics can be a reduction of foods rich in antioxidants can require long-term antibiotics to maintain associated with the development of antibiotic- predispose to pouchitis.43 symptomatic relief.34 The two antibiotics most resistant organisms.34 There have been case In terms of vitamin deficiencies, it has commonly used to treat primary idiopathic series suggesting that C. difficile infection occurs been highlighted that of patients who have pouchitis are ciprofloxacin and metronidazole. in patients who have a pouch and are taking undergone restorative proctocolectomy, 10.6% Patients should be counselled on the specific antibiotics and that they should be used have a vitamin D deficiency and 5% have either
9 ueg education Mistakes in… 2020 a vitamin A or B12 deficiency. Furthermore, in Inflammatory Bowel Disease Therapy 1996. 1997; 24. Panis Y, Poupard B, Nemeth J, et al. Ileal pouch/anal anastomosis for Crohn’s disease. 1996; patients with pouchitis may be at risk of having Springer Netherlands, 1997, p.51–63. Lancet 3. Pardi DS and Shen B. Endoscopy in the management 347: 854–857. lower levels of calcium, total cholesterol, of patients after ileal pouch surgery for ulcerative 25. Regimbeau JM, Panis Y, Pocard M, et al. Long-term triglycerides, vitamin E and iron.44,45 It is colitis. Endoscopy 2008; 40: 529–533. results of ileal pouch-anal anastomosis for colorectal Crohn’s disease. 2001; 44: 769–778. therefore important that anyone who undergoes 4. Shen B. Pouchitis: What every gastroenterologist Dis Colon Rectum needs to know. Clin Gastroenterol Hepatol 2013; 26. Bemelman WA, Warusavitarne J, Sampietro GM, et al. proctocolectomy is advised to consider eating 11: 1538–1549. ECCO-ESCP consensus on surgery for Crohn’s disease. foods rich in these vitamins and minerals to keep 5. Sandborn WJ, Tremaine WJ, Batts KP, et al. Pouchitis J Crohn’s Colitis 2017; 12: 1–16. 27. Deutsch AA, McLeod RS, Cullen J, et al. Results of the levels normal. after ileal pouch-anal anastomosis: a pouchitis disease activity index. Mayo Clin Proc 1994; 69: pelvic-pouch procedure in patients with Crohn’s Caution must also be exercised with respect 409–415. disease. Dis Colon Rectum 1991;34:475–477. to fluid balance in a patient who has a pouch. 6. Ben-Bassat O, Tyler AD, Xu W, et al. Ileal pouch 28. Grobler SP, Hosie KB and Keighley MRB. Randomized trial of loop ileostomy in restorative proctocolectomy. Normal stool frequency can be four to eight symptoms do not correlate with inflammation of the pouch. Clin Gastroenterol Hepatol 2014; Br J Surg 1992; 79: 903–906. times in a 24-hour period, and a great deal higher 12: 831–837.e2. 29. Hyman NH, Fazio VW, Tuckson WB, et al. when active pouchitis is present. Patients can 7. van der Ploeg V, Maeda Y, Faiz OD, et al. The Consequences of ileal pouch-anal anastomosis for become dehydrated46 and electrolytes depleted, prevalence of chronic peri-pouch sepsis in patients Crohn’s colitis. Dis Colon Rectum 1991; 34: 653–657. treated for antibiotic-dependent or refractory 30. Shen B, Fazio VW, Remzi FH, et al. clinical features contributing to fatigue. It can be helpful to assess primary idiopathic pouchitis. Colorectal Dis 2017; 19: and quality of life in patients with different fluid balance by checking the urinary sodium 827–831. phenotypes of crohnʼs disease of the ileal pouch. level, and consider the addition of electrolyte 8. Navaneethan U and Shen B. Secondary pouchitis: Dis Colon Rectum 2007; 50: 1450–1459. Those with identifiable etiopathogenetic or triggering 31. Shen B, Fazio VW, Remzi FH, et al. Risk factors for mix and antidiarrhoeal agents to reduce fluid factors. Am J Gastroenterol 2010; 105: 51–64. clinical phenotypes of crohn’s disease of the ileal loss. Guidance from an experienced dietitian is 9. Segal JP, Ding NS, Worley G, et al. Systematic review pouch. Am J Gastroenterol 2006; 101: 2760–2768. helpful. with meta-analysis: the management of chronic 32. Wolf JM, Achkar J-P, Lashner BA, et al. Afferent limb refractory pouchitis with an evidence-based ulcers predict Crohn’s disease in patients with ileal treatment algorithm. Aliment Pharmacol Ther 2017; pouch-anal anastomosis. Gastroenterology 2004; 126: Mistake 10 | Managing patients with pouch 45: 581–592. 1686–1691. dysfunction outside a specialist centre 10. Annerijn van der Ploeg V, Maeda Y, Faiz OD, et al. 33. Lightner AL, Fletcher JG, Pemberton JH, et al. Crohn’s Standardising assessment and documentation of disease of the pouch: A true diagnosis or an pouchoscopy. Frontline Gastroenterol 2018; oversubscribed diagnosis of exclusion? Dis Colon Restorative proctocolectomy is an operation that 9: 309–314. Rectum 2017; 60: 1201–1208. is designed to improve overall quality of life and 11. Samaan MA, Shen B, Mosli MH, et al. Reliability 34. Segal JP, Poo SX, McLaughlin SD, et al. Long-term follow-up of the use of maintenance antibiotic remove the need for an ileostomy; however, poorly among central readers in the evaluation of endoscopic disease activity in pouchitis. therapy for chronic antibiotic-dependent pouchitis. functioning pouches may impact on a patient’s Gastrointest Endosc 2018; 88: 360–369.e2. Frontline Gastroenterol 2018; 9: 154–158. life in multiple ways, resulting in nutritional, 12. Segal JP, Chan H, Collins B, et al. Biofeedback in 35. Kim GK. The risk of fluoroquinolone-induced tendinopathy and tendon rupture: what does the psychological, physical and emotional problems. patients with ileoanal pouch dysfunction: a specialist centre experience. Scand J Gastroenterol 2018; clinician need to know? J Clin Aesthet Dermatol 2010; It is therefore essential that a patient who has a 53: 665–669. 3: 49–54. pouch is given access to a broad range of 13. Shen B. Diagnosis and management of postoperative 36. Goolsby TA, Jakeman B and Gaynes RP. Clinical relevance of metronidazole and peripheral healthcare professionals who have the skills and ileal pouch disorders. Clin Colon Rectal Surg 2010; 23: 259–268. neuropathy: a systematic review of the literature. Int J experience necessary to support their various 14. Shen B, Lashner BA, Bennett AE, et al. Treatment of Antimicrob Agents 2018; 51: 319–325. needs. If a pouch starts to function poorly, it is rectal cuff inflammation (cuffitis) in patients with 37. Seril DN and Shen B. Clostridium difficile infection in patients with ileal pouches. Am J Gastroenterol 2014; vital that early discussions are held with the ulcerative colitis following restorative proctocolectomy and ileal pouch-anal anastomosis. 109: 941–947. multidisciplinary team so that all management Am J Gastroenterol 2004; 99: 1527–1531. 38. Herfarth HH, Long MD and Isaacs KL. Use of biologics options, including surgery, are considered. 15. Thompson-Fawcett MW, Mortensen NJ and Warren in pouchitis. J Clin Gastroenterol 2015; 49: 647–654. 39. Weaver KN, Gregory M, Syal G, et al. Ustekinumab is Specialist pouch nurses, gastroenterologists, BF. Cuffitis and inflammatory changes in the columnar cuff, anal transitional zone, and ileal effective for the treatment of crohn’s disease of the surgeons and dietitians are needed to ensure reservoir after stapled pouch-anal anastomosis. pouch in a multicenter cohort. Inflamm Bowel Dis effective service delivery. Joint medical and Dis Colon Rectum 1999; 42: 348–355. 2019;25:767–74. doi:10.1093/ibd/izy302 40. Gregory M, Weaver KN, Hoversten P, et al. Efficacy of surgical clinics can help to achieve a holistic 16. Thompson JS. Cuffitis: A new cause of pouch dysfunction. Am J Gastroenterol 1999; 94: 2007. vedolizumab for refractory pouchitis of the ileo-anal review of a patient’s quality of life and offer the 17. Wu B, Lian L, Li Y, et al. Clinical course of cuffitis in pouch: results from a multicenter US cohort. full range of treatment options. As pouch surgery ulcerative colitis patients with restorative Inflamm Bowel Dis 2019; 25: 1569–1576. 41. ‘Study to compare alicaforsen with placebo in is not frequently performed, we recommend proctocolectomy and ileal pouch–anal anastomoses. Inflamm Bowel Dis 2013; 19: 404–410. patients with pouchitis’ NHS Health Research that, whenever possible, pouch care should be 18. Phillips RK. Ileal pouch-anal anastomosis for Crohn’s Authority https://www.hra.nhs.uk/planning-and- centralised to units that perform a high volume disease. Gut 1998; 43: 303–304. improving-research/application-summaries/ research-summaries/study-to-compare-alicaforsen- of these operations and have the healthcare 19. Hartley JE, Fazio VW, Remzi FH, et al. Analysis of the outcome of ileal pouch-anal anastomosis in patients with-placebo-in-patients-with-pouchitis/ (accessed support staff and infrastructure needed to with Crohn’s disease. Dis Colon Rectum 2004; April 2020). manage pouch-related problems. Furthermore, 47: 1808–1815. 42. Godny L, Maharshak N, Reshef L, et al. Fruit consumption is associated with alterations in patients should have a point of contact, much 20. Brown CJ, Maclean AR, Cohen Z, et al. Crohn’s disease and indeterminate colitis and the ileal pouch-anal microbial composition and lower rates of pouchitis. like an ‘IBD nurse’, so they can discuss problems anastomosis: outcomes and patterns of failure. J Crohn’s Colitis 2019; 13: 1265–1272. with their pouch and be directed to the right Dis Colon Rectum 2005; 48: 1542–1549. 43. Ianco O, Tulchinsky H, Lusthaus M, et al. Diet of patients after pouch surgery may affect pouch services early. 21. Yu CS, Pemberton JH and Larson D. Ileal pouch-anal anastomosis in patients with indeterminate colitis: inflammation. World J Gastroenterol 2013; 19: 6458. long-term results. Dis Colon Rectum 2000; 44. Kuisma J, Nuutinen H, Luukkonen P, et al. Long term References 43: 1487–1496. metabolic consequences of ileal pouch-anal 22. Keighley MR. The final diagnosis in pouch patients for anastomosis for ulcerative colitis. Am J Gastroenterol 1. Lepistö A, Luukkonen P and Järvinen HJ. Cumulative presumed ulcerative colitis may change to Crohn’s 2001; 96: 3110–3116. failure rate of ileal pouch-anal anastomosis and disease: patients should be warned of the 45. Pastrana RJ, Torres EA, Arroyo JM, et al. Iron- quality of life after failure. Dis Colon Rectum 2002; consequences. Acta Chir Iugosl 2000; 47: 27–31. deficiency anemia as presentation of pouchitis. 45: 1289–1294. doi:10.1007/s10350-004-6412-9 23. Gu J, Stocchi L, Kiran RP, et al. Do clinical J Clin Gastroenterol 2007; 41: 41–44. doi:10.1097/01. 2. Sandborn WJ. Pouchitis: definition, risk factors, characteristics of de novo pouch crohns disease mcg.0000212641.90477.d0 frequency, natural history, classification, and public after restorative proctocolectomy affect ileal 46. Helavirta I, Huhtala H, Hyöty M, et al. Restorative health perspective. In: Sutherland LR, Mcleod RS, pouch retention? Dis Colon Rectum 2014; proctocolectomy for ulcerative colitis in 1985–2009. 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10 ueg education Mistakes in… 2020
Your pouchitis briefing
UEG week Surveillance, Surgery, and Ileo-anal Pouch Disorders. • ‘Therapy Update: Ulcerative colitis’ session at UEG J Crohn’s Colitis 2017; 11: 649–670. Week 2019 [https://ueg.eu/library/third - european [https://ueg.eu/library/session/ - evidence-based-consensus-on-diagnosis-and-man- therapy-update-ulcerative-colitis/156/2209]. agement-of-ulcerative-colitis-part-1-definitions-diagno- sis-extra-intestinal-manifestations-pregnancy-cancer- • ‘Ulcerative colitis: Current management’ session at surveillance-surgery-and-ileo-anal-pouch-disor- UEG Week 2019 [https://ueg.eu/library/session/ ders/150756]. ulcerative-colitis-current-management/156/2135]. • Langner C, et al. The histopathological approach to Standards and Guidelines inflammatory bowel disease: a practice guide. • Turner D, et al. Management of paediatric ulcerative Virchows Arch 2014; 464: 511–527. colitis, part 1: Ambulatory care—an evidence-based [https://ueg.eu/library/ guideline from European Crohn’s and Colitis the-histopathological-approach-to-inflammatory- Organization and European Society of Paediatric bowel-disease-a-practice-guide/128280]. Gastroenterology, Hepatology and Nutrition. • Van der Woude CJ, et al. The Second European J Ped Gastroenterol Nutr 2018; 67: 257–291. Evidenced-Based Consensus on Reproduction and [https://ueg.eu/library/management - of-paediatric Pregnancy in Inflammatory Bowel Disease. J Crohn’s -ulcerative-colitis-part-1-ambulatory-care-an-evi- Colitis 2015; 9: 107–124. [https://ueg.eu/library/ dence-based-guideline-from-european-crohn-s-and- the-second-european-evidenced-based-consensus- colitis-organization-and-european-society-of-paediatr- on-reproduction-and-pregnancy-in-inflammatory- ic-gastroenterology-hepatology-and-nutri- bowel-disease/125372] tion/178427]. • Öresland T, et al. European evidence based consensus • Magro F, et al. Third European Evidence- on surgery for ulcerative colitis. J Crohn’s Colitis 2015; 9: based Consensus on Diagnosis and Management 4–25 [https://ueg.eu/library/ of Ulcerative Colitis. Part 1: Definitions, Diagnosis, european-evidence-based-consensus-on-surgery-for- Extra-intestinal Manifestations, Pregnancy, Cancer ulcerative-colitis/125373]
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